Notes on the interface of medicine, society, psychiatry and public health

Followers

Monday, January 6, 2014

Medicalizing Misery and the Loss of Social Suffering

The
real money always lay not in convincing sick people they were ill, but well
people they were sick

Throughout the 1990s, the UK Royal
College of Psychiatrists and Royal College of General Practitioners, enabled
generously by the pharmaceutical industry, campaigned to educate clinicians and
the public about depression and its treatment. The Defeat Depression campaign
was pithily encapsulated in the slogan: “Depression. Treat it. Defeat it.”Today depression is so overdiagnosed, that a
recent study found that over 60% of those diagnosed did not meet the diagnostic
criteria for a major depressive episode, rising to over 90% of those over the
age of 65. A recent article in the BMJ
claims that the DSM-5, by expanding the definition of depressive illness to
include reactions to bereavement, will further erode the concept of normal
sadness, leading to more people incorrectly diagnosed and treated for
depression. If not depressive illness, what are we experiencing? The answer:
social suffering.

The changing face of depression

From 1992 to 1996, the Royal
Colleges of General Practitioners and Psychiatrists led the Defeat Depression
campaign, to raise public awareness of depression as a medical illness, and to
educate professionals to diagnose and treat it. A UK survey of public attitudes
at the time found that 85% believed counseling to be effective but were against
antidepressants, and almost 80% believed antidepressants were addictive. By
2003, traces of metabolites of the antidepressant Prozac would be found in the
water supply. By 2012, 50 million antidepressant prescriptions were issued in
England alone, with 1 in 6 people in some areas using antidepressants. This is
despite the number of people suffering from depressive illness at any one time
staying roughly stable at about 6%. How did this sea-change occur? So
successful was the public education campaign and other sources of information,
that many people have now come to believe that depression is caused by a
chemical imbalance in the brain that is corrected by antidepressants. As the
sociologist Nikolas Rose notes, we have come to recode our moods in terms of
neurotransmitters, and identity in what he calls ‘the neurochemical self’. In
addition, primary care doctors who bear the brunt of the endemic minor misery
were heavily pushed into screening for depression, and reimbursed on quality
measures including documenting depression scores of self-report rating scales
like the PHQ-9. The result was an increase in new antidepressant prescriptions
throughout the 1990s. This was coupled with the lack of availability of
psychological treatments, with waiting lists in some areas as long as two
years.

Although the detection of hitherto
unnoticed individuals who suffered extreme mental anguish explain some of the
rise in depression diagnoses and antidepressant prescriptions, in the early
2000s something strange happened. In the UK at least, the number of new
prescriptions for antidepressants weren’t increasing, but the overall number of
prescriptions were. That is to say, it wasn’t that more and more people were being
prescribed antidepressants, it was that those who were on them continued.
Depressive illness, once thought of as a temporary aberration, sometimes chronic
and lifelong, was becoming more chronic. It is likely that antidepressants
themselves may have played some role in this. There is some suggestion that
some individuals on long-term antidepressant use will become depressed as a
result of the chemical changes occurring in their brain, the so-called tardive dysphoria syndrome. Part of this is likely psychological too – in the narrative
of chemical imbalances, taking antidepressants is just like insulin for
diabetes. If you stop taking your antidepressant won’t your chemical imbalance
come back? Further, by locating the source of distress inside a broken brain or
twisted molecules we have disempowered individuals to take charge of their
lives. The reality is, as I discussed previously, the notion that depression or
any mental illness is caused by chemical balances is an oversimplification at
best and a myth at worst. That is not to say there is no biological basis to
depressive states, but this despair cannot be meaningfully reduced to aberrant
brain chemistry.

The currency of depression

Today the word depression provides
a currency of validation. When we see a doctor feeling deflated, tired,
sleepless, joyless, or sad, a diagnosis of depression is like a badge of honor
for the wounded warrior, it confers recognition that we have suffered so. There
is something reassuring to hear an ‘expert’ tell us they know what is wrong and
they know how to help. When you feel like you are drowning, a prescription for
a pill, is like a lifeline that keeps you afloat. And even though you know the
reasons you feel so terrible, which you are constantly reminded of, it becomes
convenient to believe that something as simple as a chemical imbalance is at
the root of it all. Even if you realize that the remedy may be in deeper
psychological work, having more money, a better relationship, a better economy,
better behaved children, a sense of self-worth, or even taking better care of
yourself, those things are unavailable or not forthcoming. We make do with
what’s on offer. And what’s on offer is antidepressants.

Incidentally, whilst states of
despair and misery have existed throughout time and space, depression only has
currency in the West in recent times. In China whilst the same syndrome of
major depressive disorder is recognizable, it has no cultural cachet. Instead
the diagnosis of neurasthenia is made. In Zimbabwe, anxious and depressive
ruminations are captured by the term ‘kifungisisi’ (which is included in the DSM-5) which means 'thinking too
much'. In Somalia, there is no linguistic concept of depression. The closest
thing is ‘Qu’lub’ which translates as ‘the feelings a camel has when its friend
dies’. In Latvia, the term “nervi” or damaged nerves captured the endemic
suffering following the fall of the Soviet Union. Depression is as much a
cultural concept as it is a biological one.

Whither Social Suffering?

In the anthropological literature,
there is a concept that describes the misery that individuals experience in
contexts where they are powerless, where things have no prospect of improvement,
and the feelings are entirely understandable. The concept is that of social
suffering. In the medical and psychiatric literature, little attention has been
paid to this concept, yet it afflicts the majority in large parts of the world
who are indeed the inhabitants of unstable and uncertain sociopolitical
landscapes. Although this term is often applied to those in developing
countries, it seems apt to describe many patients in the developed world as
afflicted by social suffering too.

It is not surprising that
psychiatrists have neglected social suffering. There isn’t a pill for it. We
may empathically bear witness to the suffering of others, but that only goes so
far. It is not surprising either that these individuals are incorrectly
diagnosed as depressed, and that this misdiagnosis increases in those over 65
and live in a world that has no use and sees no value in those who no longer
work. It’s much easier for everyone to transform this endemic misery into
depressive illness, because if it’s depressive illness then it may benefit from
medical or psychological remedy. Those in primary care feel an enormous pressure
to ‘do something’ and prescribing a pill is easy enough. It temporarily
satisfies both patient and clinician that something has been done. The reality
is by seeing the individual as a problem, we conveniently ignore the wider
social, economic, and political forces that oppress, and yes, depress. These are
problems that need resolution through public policy, and not through pills or
psychotherapy.

Blame the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders is certainly
beleaguered with problems, but the emphasis on the description of major
depression as being responsible for overdiagnosis is just not true. The DSM is
irrelevant to clinical practice, especially in primary care, because nobody
uses it. People who felt depressed following bereavement were diagnosed and
treated for depression long before the DSM-5 and will continue to do so. Sadly,
the DSM-5 does not include a term that would aptly describe much of what we
see, without labeling it a mental illness. That term is demoralization. Many of
the patients I see are demoralized by their situation – in the face of a
relationship they cannot escape from, a diagnosis of terminal illness, dashed
career hopes. This is not an illness, but it deserves recognition.

As discussed above, most people
diagnosed with depression don’t meet the criteria for DSM major depressive
disorder. This isn’t because doctors can’t tell the difference between normal
sadness and depressive despair. It’s because, when you have 10 minutes to see
someone, and they tell you they’re depressed, and they want your help, and you
feel pressure to ‘do something’ you are going to tell them they’re depressed
and you’re going to give them what they want. And in the UK at least, there was
a whole campaign that told you that’s exactly what you were supposed to do.

The medicalization of endemic
misery and its medical treatment is our own doing. It takes time and resources
away from the management of those with more serious physical and mental
maladies, and is profitable for neither clinicians nor patients. The one actor
that has profited, and handsomely at that, is the pharmaceutical company. The
real money always lay not in convincing sick people they were ill, but well
people they were sick. And so we continue to mask social suffering in the guise
of depression.

Your last sentence: "Current psychiatric training does not adequately meet these needs, and if not remedied, will lead to the continuing criticism and marginalization of psychiatry in medicine." Do you imagine you're dealing with a profession (we agree that that's its status, at the moment) concerned only with the interests of its members? That would seem to be so given that you plunge the dagger many times and yet the coup de grace is that psychiatry might become marginalized in medicine. As someone who has been on the receiving end of psychiatric oppression (including DWT) and admittedly not your target in writing this diatribe - that would be no loss at all.